Benguet State University

COLLEGE OF NURSING
La Trinidad, Benguet
Date ASSESSMENT (Problem Statement/Nursing Diagnosis) NURSING CARE PLAN (Objective/Goal)
Acute Pain related to emergency debridement and application of After 5 hours of nursing After 3 days of nursing
external fixation secondary to fracture, open complete interventions, the client interventions, the client
displaced, Middle 3rd Fabia Left will be able to report pain will be totally free from
is relieved and controlled. break through pain.

Individual Problems (CUES) IMPLEMENTATION

APPROACHES
1. Note location of surgical procedure.
S>
“Nasakit nga unay diay sakak.” pain 2. Obtain assessment of pain to include
noted as 7/10; characterized as throbbing location, severity and quality.
pain. 3. Observe nonverbal cues and pain behaviors.
4. Stay on bedside at all times.
O> 5. Provide comfort measures such as
 appears restless repositioning.
 grimace noted 6. Provide ample time to rest.
 self focusing: reduced interaction 7. Instruct use of relaxation techniques like
with significant others and health deep breathing exercises.
care providers 8. Encourage to verbalize feelings, thoughts
and concerns.
RATIONALE
>Can influence the amount of postoperative pain
experienced
> To rule out worsening of underlying condition of
development of complication
>Observations may not be congruent with verbal reports
or may be only indicator present when client is unable to
verbalize.
>To attend to needs
>To promote non pharmacological pain management
>To prevent fatigue
>To alleviate and control pain
>To assist to explore methods for control of pain

ACTUAL OUTCOME Date & Time Received

GOAL MET: After 5 hours of nursing interventions, the client was able to
report pain is controlled noted as 4/10.
 Benguet State University
COLLEGE OF NURSING
La Trinidad, Benguet
Date ASSESSMENT (Problem Statement/Nursing Diagnosis)
Impaired Physical Mobility related to emergency debridement
and application of long leg posterior splint secondary to fracture,
open complete displaced, Middle 3rd Fabia Left
Individual Problems (CUES) IMPLEMENTATION
APPROACHES
1. Assess for impediments to mobility.
S>
“Hanku maigaraw dyty kanigid nga 2. Assess patient’s ability to perform ADL
sakak kn pati dyty bagik.” effectively and safely on a daily basis.
3. Assess patients and caregiver’s knowledge
O> of immobility and its complications.
 Limited Range of Motion
 Limited ability to perform gross 4. Keep side rails up and bed in low position.
motor skills such as sitting up 5. Turn and position every 2 hours as needed
 Functional level classification: 2- as long as it is not contraindicated.
requires help from significant 6. Maintain limbs in functional alignment.
others for assistance and
supervision 7. Perform passive ROM exercises to all
extremities.
8. Encourage and facilitate early ambulation
and other ADL when possible.
9. Encourage fluid intake of 2000 to 3000 mL
per day.
ACTUAL OUTCOME
GOAL MET: After 5 hours of nursing interventions the client was able to
perform physical activity within limits and used safety measures to minimize
potential for injury.
NURSING CARE PLAN (Objective/Goal)
Within 8 hours of nursing After 2-3 days of nursing
interventions, the client intervention, the client will
will be able to perform be free from complications
physical activity within of immobility as evidenced
limits and use safety by intact skin.
measures to minimize
potential for injury.
RATIONALE
>Identifying the specific cause guides design of optimal
treatment plan.
>Restricted movement affects the ability to perform most
ADL. Safety is an important concern.
>Patients who are temporarily immobile are at risk for
some of the effects of immobility such as skin breakdown
and muscle weakness.
>To promote safe environment.
>To optimize circulation to all tissues and to relieve
pressure.
>To prevent foot drop and excessive plantar flexion or
tightness.
>To promote increased venous return, prevent stiffness
and maintain muscle strength and endurance.
>The longer the patient remains immobile the greater the
level of debilitation that will occur.
>To optimize hydration status and prevent hardening.
Date & Time Received
 Benguet State University
COLLEGE OF NURSING
La Trinidad, Benguet
Date ASSESSMENT (Problem Statement/Nursing Diagnosis) NURSING CARE PLAN (Objective/Goal)
Activity Intolerance related to Fracture After 8 hours of After 2-3 days of
intervention, patient will interventions, patient will
be able to perform ADLs be able to maintain
with some assistance. activity level within
capabilities.

Individual Problems (CUES) IMPLEMENTATION

APPROACHES
1. Assess current condition.
S>
“Hindi ko maigalaw itong paako kaya di 2. Check ability to perform ADL.
ako makatayo.”
3. Assist in performing ROM exercises.
O>
 Can’t perform some ADL alone 4. Promote in dependence in self-care
 Limited range of motion activities as tolerated.
 Weak in appearance
5. Advise alternating activity with rest.
6. Encourage to verbalize concerns.
RATIONALE
>Provides complementary data for proper nursing
interventions
>Promotes circulation and avoids pressure ulcers
>Mild/moderate activities &improved self-esteem are
promoted
>Minimize exhaustion &helps balance O2 supply and
demand.
>From prompt and proper intervention

ACTUAL OUTCOME Date & Time Received

GOAL MET: After 8 hours of nursing intervention, patient was receptive to
care and was able to perform ADLs with some assistance by the nurse
learner and SO.
 Benguet State University
COLLEGE OF NURSING
La Trinidad, Benguet
Date ASSESSMENT (Problem Statement/Nursing Diagnosis) NURSING CARE PLAN (Objective/Goal)
Impaired Skin Integrity related to emergency debridement and After 8 hours of nursing After 3 days of nursing
application of external fixation secondary to fracture, open interventions, patient will interventions, the client
complete displaced, Middle 3rd Fabia Left be able to verbalize relief will be able to display
of discomfort and timely healing.
demonstrate behaviors to
prevent skin breakdown
and facilitate healing.

Individual Problems (CUES) IMPLEMENTATION

APPROACHES RATIONALE
1. Examine surgical incision for bleeding and >Provides information regarding skin circulation and
S> the surrounding area for dislocation, rashes edema formation that may require further medical
“Namin duwa ak nga napan OR.” As and swelling. intervention.
claimed 2. Determine degree and depth of injury to the >To assess extent of injury
skin.
O> 3. Evaluate client’s skin care practices and >To assess contributing factors that may lead to the
 With dry and intact dressing on the hygiene issues. condition
surgical site 4. Keep the area clean and dry by assisting in >To assist clients body in natural process of repair and to
 With minimal bleeding on the wound dressing. promote optimal healing.
surgical site 5. Place pillow or other padding under knees >Reduces pressure on the area and prevents skin
 Tender to touch as indicated. breakdown.
 No swelling around incision site 6. Reposition frequently. >Lessens constant pressure on the same areas and
minimizes risk of skin breakdown.
VS as follows: 7. Provide adequate periods of rest and sleep. >To promote optimal healing by maximizing energy
BP: 120/80 mmhg 8. Encourage optimum nutrition which >To aid in skin and tissue healing
CR: 68 bpm includes increasing intake of protein rich
RR: 19 cpm food such as lean meat and chicken.
Temp: 36.8 degree celcius
SPO2: 97%

ACTUAL OUTCOME Date & Time Received

GOAL MET: After 8 hours of nursing interventions, patient was able to
demonstrate behaviors to prevent skin breakdown and facilitate healing as
evidenced by return demonstration of proper wound cleaning and dressing.
 Benguet State University
COLLEGE OF NURSING
La Trinidad, Benguet
Date ASSESSMENT (Problem Statement/Nursing Diagnosis) NURSING CARE PLAN (Objective/Goal)
Self-Care Deficit related to inability to ambulate secondary to After 8 hours of After 2-3 days of
Fracture intervention, patient will interventions, patient will
be able to perform be able to perform
self-care with assistance self-care within own
capabilities

Individual Problems (CUES) IMPLEMENTATION

S>
“Diko malinisan sarili ko kasi hindi ko
kayang pumunta sa CR.”
O>
 Inability to dress self independently
 Inability to bathe and groom self
independently
 Inability to perform toileting tasks
independently
 Inability to ambulate independently
APPROACHES
1. Assess current condition and level of action >Provides complementary data for intervention
tolerated.
2. Plan activities to avoid fatigue.
3. Use consistent routines and allow for
adequate time for task completion.
4. Provide privacy.
5. Assist in dressing.
6. Advise using clothes 1 size larger.
7. Encourage to verbalize concerns.
RATIONALE
>Conserve energy
>Helps in organizing and carry out self-care skills
>Reduce anxiety and is fundamental for most patients
>Ensures safety and easier dressing
>Easier to wear
>For prompt interventions

ACTUAL OUTCOME Date & Time Received

GOAL MET: After 8 hours of intervention, Goal was met. Patient was
receptive to care and was able to perform self-care with assistance.
 Benguet State University
COLLEGE OF NURSING
La Trinidad, Benguet
Date ASSESSMENT (Problem Statement/Nursing Diagnosis) NURSING CARE PLAN (Objective/Goal)
Risk for infection After 8 hours of After 2-3 days of
intervention, patient will interventions, patient will
be able to verbalize be able to free of signs
understanding and and symptoms of infection
willingness to follow
teachings

Individual Problems (CUES) IMPLEMENTATION

APPROACHES
1. Note risk factors for occurrence of infection.
2. Observe for localized sign of infection at
insertion sites of invasive lines, surgical
O> incisions or wounds.
 Presence of External Fixation 3. Administer and instruct precautions
regarding medication regimen and note
client’s response.
4. Emphasize necessity of taking antibiotics, as
directed.
5. Review environmental factors.
6. Encourage to verbalize concerns.
RATIONALE
>to evaluate presence/ character of infection
>to evaluate presence/ character of infection.
>to determine effectiveness of therapy and if there is a
presence of side effect
>to inform the client the risk of discontinuation of
treatment
>to assess if there is a need of avoidance or modification
of environment to reduce incidence of infection.
>For prompt and proper intervention

ACTUAL OUTCOME Date & Time Received

GOAL MET: After 2 hours of nursing intervention, patient was able to
verbalize understanding and showed signs of willingness to participate in
made regimen.